Request for Letters of Certification/Clearance
($5.00 Fee Per Letter)
Date ________________________________ Please complete the following by indicating the number and type of Certification/Clearance Letters you are requesting. Letter of Certification on an Individual Letter of Certification on an Agency Letter of Clearance _______ _______ _______
Please Note: When requesting a Letter of Clearance – all licenses for that licensee will be terminated.
Name of Licensee_________________________________________ SSN_________________________ Address ________________________________________ City/State/Zip _________________________ License No. _____________________________________ License Type _________________________ Name of Agency _________________________________________ E.I.N. _______________________ Address ________________________________________ City/State/Zip _________________________ License No. _____________________________________ License Type _________________________
Requested by: ___________________________________ Phone No. ____________________________ Address ________________________________________ City/State/Zip _________________________ Signature _______________________________________ (Clearance Letter requests must be signed by the licensee)
NOTE: Each State Insurance Commissioner may verify the Producer’s licensing status through the National Producer Database maintained by the National Association of Insurance Commissioners, its affiliates or subsidiaries. It may not be necessary to request a Letter of Certification. Please check with the State in which you are applying.